Page 966 - Small Animal Clinical Nutrition 5th Edition

1000 Small Animal Clinical Nutrition

Questions
VetBooks.ir 1. At what age should periodontal therapy be discontinued due to anesthetic risks?
2. When are antibiotics appropriate in periodontal therapy?
3. What medications may have adverse oral effects, particularly in geriatric dogs?
4. Is maintenance of alveolar bone under the tooth (alveolar ridge) a concern when extracting permanent teeth?
5. Outline an appropriate feeding plan for this geriatric patient.

Answers and Discussion
1. Many owners and veterinarians are reluctant to anesthetize geriatric patients for periodontal procedures.There is no specific age,
however, when a patient cannot be anesthetized. An appropriate preanesthetic assessment should be made in all cases to identi-
fy potential risks and define an appropriate anesthetic regimen. Placing an intravenous catheter and administering fluids during
periodontal procedures reduces the risk of anesthetic complications. Periodontal disease is associated with bacterial infection.The
potential for systemic disease due to chronic showering of the bloodstream with oral bacteria may pose a greater risk to the patient
than the anesthesia required for appropriate periodontal therapy.
2. Antibiotics may be used before, during or after dental procedures. Each period has specific justification. Antibiotics used before
dental procedures help control the existing periodontal infection, thereby decreasing inflammation, which allows for more accu-
rate clinical assessment and helps when making therapeutic choices. Antibiotics used during dental procedures are generally
administered to protect the body from infection resulting from bacteremia. Healthy immunocompetent patients clear this bac-
teremia within 20 minutes. However, patients with organ pathology or a compromised immune system may be predisposed to
sequential infection. Antibiotics given after dental procedures are generally prescribed to prevent oral reinfection during the heal-
ing stages.
3. Many medications can affect oral physiology, particularly salivary flow. Saliva is rich in proteins, glycoproteins, electrolytes and
lipids and provides a protective barrier to oral tissues. Reduced salivary flow is associated with an increased prevalence of caries,
periodontal disease and oral irritation in people. Patients receiving medications that alter the oral environment may need addi-
tional professional or homecare to maintain oral health. Examples of such drugs include narcotic analgesics, anticonvulsants, anti-
histamines, antiarrhythmics, antineoplastics, antiemetics, diuretics and tranquilizers.
4. Alveolar ridge maintenance is a concern, particularly if the mandibular incisor, canine or carnassial teeth are extracted. Atrophy
of the alveolar ridge and mandibular weakening are common following extraction of these teeth, and may result in future patho-
logic or iatrogenic fractures. Packing extraction sites with osseopromotive material may reduce and in some cases prevent alveo-
lar ridge atrophy.
5. Because aging affects all body systems, there is a high likelihood of multiple problems in older pets. A thorough systems review,
which should include a complete history, physical examination and extended laboratory database, is important in older pets.This
review enables the veterinarian to define problems accurately, prioritize the problems and establish appropriate diagnostic, ther-
apeutic and feeding plans. Chronic valvular heart disease (endocardiosis) and renal failure are common causes of morbidity and
mortality in older dogs. Because these conditions are so common, geriatric dogs may benefit from a food that avoids excess lev-
els of phosphorus, protein, sodium and chloride (Chapters 36 and 37). Other nutrient levels and the feeding method may need
to be adjusted based on body condition of the patient and results of the comprehensive systems review.
This dog has clinical and laboratory evidence of dental disease, chronic valvular heart disease and renal disease. Accordingly, it
may benefit from a food that avoids excess levels of phosphorus, protein, sodium and chloride. In addition, oral care at home
should be initiated to prevent accumulation of dental substrates and further periodontal disease. A food or dental treat that
enhances mechanical cleansing or teeth would be appropriate.
b
Prescription Diet t/d Canine is a dry veterinary therapeutic food formulated to reduce accumulation of plaque and calculus
and reduce gingivitis.This food is most effective when fed as the sole maintenance food for adult dogs. However, some pets with
dental disease should receive food(s) with different nutrient profiles because of concurrent disease.

Progress Notes
The dog was given a vasodilator (isosorbide dinitrate) and a moist veterinary therapeutic food that avoids excess phosphorus, pro-
b
tein, sodium and chloride (Prescription Diet k/d Canine ).
Therapeutic options for the oral problems were discussed with the owner and the decision was made to proceed with periodon-
tal therapy. The dog was anesthetized with isoflurane (administered via mask and intubation), and supragingival scaling followed
by root planing and subgingival curettage was performed. Severe periodontal disease was present around the left mandibular fourth
premolar and first molar teeth. Advanced bone loss was noted around the distal roots (Figure 1); a mobility index of 3/3 (severe
mobility) was present. Both teeth were extracted by crown sectioning and elevation. The alveolar sockets were curetted and bony
c
spicules were smoothed. An osseopromotive bioactive material (Bioglass ) was placed into the sockets to aid in alveolar ridge main-
d
tenance.The extraction sites were closed with sutures and the remaining teeth were polished. Oral clindamycin (Antirobe ), an oral
e
ascorbic acid/zinc gluconate rinse (Maxiguard ) and the moist veterinary therapeutic food (Prescription Diet k/d Canine) were pre-